"Lots of GPs are dropping out of
providing complex longitudinal care," says Dr Bill Cavers,
co-chair of British Columbia's GP Services Committee.
"They're moving to walk-in clinics and 'boutique' clinics."
The reason's simple: too much work for not enough money.
But the GP Services Committee thinks the solution's
simple too: more cash.
So, to stem this exodus of FPs
from full-service family medicine practices, the province
has added two new billing codes to encourage them to
stay put.
"One of the problems with fee-for-service
is that if there is just the same payment for a simple
thing compared to a complex, time-intensive thing, the
tendency for doctors is to migrate to the simpler thing,"
explains Dr Cavers.
Introduced last month, the two
incentives are additions to the ongoing Full Service
Family Practice Incentive Program, introduced in 2003.
Both are designed to remunerate physicians for taking
on complex cases that take longer to treat. "A doctor
in a walk-in clinic can see two or three patients in
the same time," says Dr Cavers. "We are trying to make
sure a doctor is not penalized for doing the heavy lifting."
NEW
INCENTIVES
The first of the new incentives, called the Complex
Patient Care Fee, pays up to $315 extra per year for
each patient who has two or more major chronic illnesses.
This incentive is available for doctors to bill for
a patient who has any two conditions from the approved
list of diabetes mellitus (type I or II), chronic renal
failure with an excretory glomerular filtration rate
of less than 60ml per minute, congestive heart failure,
asthma, COPD, cerebrovascular disease or ischemic heart
disease (excluding the acute phase of MI).
The second, called the Prevention
Fee: Cardiovascular Risk Assessment, provides $100 per
eligible patient (up to a maximum of 30 patients per
year) who's given a cardiovascular risk assessment and
related follow-up visit. This incentive reflects the
growing demand for preventive medicine — presumed
to be a cost-saving measure over the long haul —
by attempting to catch ailments like diabetes and metabolic
syndrome. Eligible patients are men between the age
of 40 and 49 and women between 50 and 59.
PERSISTENT
DOUBTS
Despite the incentives' widespread support from physician
organizations, the BC College of Family Physicians has
a few concerns.
"I've read through the multi-page
explanations of these billing codes and it strikes me
as quite complex and not a typical fee-for-service billing,"
says the College's president Dr Jim Thorsteinson. "It
may be difficult to incorporate into practices' billing,
and it will take some work with office staff to make
this work." Practices using EMR systems will find it
much easier to track eligible patients and billable
visits. One EMR vendor has already programmed the incentives
directly into its software so physicians don't even
have to think about how to bill for them.
Continuity of care is another concern,
Dr Thorsteinson says. "It's not typical that patients
will see just one physician, and this [incentive program]
is supposed to be for patients with ongoing care." A
solution to this problem might be to enforce a patient-roster
system in the future, he suggests.
"The issue of P4P [pay-for-performance]
is still out there," adds Dr Thorsteinson. "We'll have
to see if tracking proxies is associated with the presumed
good outcomes. We'll have to give it some years to see
if individual tests can improve outcomes," he adds,
referring to the Cardiovascular Risk Assessment incentive.
Dr Cavers admits the incentives
are no magic bullet for family physicians. "It's a trial,
to see if it has the outcomes we want." But past experiments
have been promising. BC incentives for family doctors
to test for diabetes have already proven effective.
According to Dr Cavers, patients of GPs who billed for
those incentives had about a 70% chance of receiving
guideline-based care. Patients whose GPs didn't go for
the incentives stood only about a 30% chance.
The two new incentives bring the
total number now available to BC family physicians to
eight. New incentives will be announced this fall for
family physicians to provide care to patients suffering
from depression and anxiety.
|
BC's full FP incentive menu
| Incentive |
How much? |
Patient profile |
| Expanded Full Service Family Practice |
$125 per year per patient ($50 for hypertensive
patients) |
Congestive heart failure, diabetes and hypertension
guideline-based management |
| Family Physician Obstetrical Premium |
50% bonus on FFS payment |
Obstetrics |
| One Time Incentive Payments |
One time payment of $2,500* |
Ten patients with diabetes or congestive
heart failure and/or five deliveries over
a year |
| Maternity Care Network Initiative |
$1,500 quarterly |
Obstetrics — GPs must form care network
with at least one other physician |
| Facility Patient Conferencing Fee |
$40 |
Planning for inpatients such as frail elderly,
palliative care or mentally ill |
| Community Patient Conferencing Fee |
$40 per patient |
Complex community-based cases; care planned
with other healthcare providers, family |
| Complex Patient Care Fee |
$315 per year |
Patients with two or more chronic illnesses |
| Prevention Fee: Cardiovascular Risk Assessment |
$100 per year per patient |
Middle-aged patient per year for CVD screening |
*One time followup payment
of $7,500 available
|
|
